Edgecombe Health Center by Harborview

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

52.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 158 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 63.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 167 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 159 beds and averages 138.0 residents a day — about 87% occupied, or roughly 21 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.10 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.77 hrs/resident/day on weekends vs 3.24 on weekdays — 15% thinner on weekends. RN hours go from 0.50 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

19 citations, most serious first. The 14 most serious are shown; the remaining 5 are one tap away and print in full.

• Immediate jeopardy · J2026-06-09 · tag F0711 — isolated
  Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, the Physician and Nurse Practitioner (NP), the facility failed to ensure that Nurse Practitioner visits were comprehensive and included a review of the Medication Administration Records (MARs). On [DATE], an emergency room (ED) physician prescribed Lasix (furosemide) 20 milligrams (mg), (diuretic/water pill) daily for 3 days and Prednisone 20 mg, 3 tablets daily for 5 days for dyspnea (shortness of breath), Chronic Obstructive Pulmonary Disease exacerbation (long term lung conditions that cause irreversible damage to the airway), and fluid overload (retention of water and sodium). On [DATE], a nurse entered the Prednisone order into the electronic record but did not activate a 5-day stop date. As a result, the medication remained active and continued to be administered until [DATE]. On [DATE], the NP completed a follow-up visit after the ED encounter and acknowledged the Prednisone and Lasix orders but did not verify the medication administration record. The NP…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2026-06-09 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff, Pharmacy Consultant, Pharmacy Quality Assurance Manager, and Physician interviews, the facility failed to have effective systems in place for accurate acquiring of medications and the pharmacy failed to have effective systems in place to prevent refilling a medication order 3 times after the stop date. On [DATE] Resident #162 was seen in the emergency department (ED) for shortness of breath, dyspnea, COPD exacerbation and fluid overload and returned to the facility just before midnight. The ED Physician prescribed Prednisone 20 mg (milligrams) 3 tablets (total of 60 mg daily) at breakfast for 5 days for diagnosis of dyspnea (shortness of breath or difficulty, uncomfortable breathing), chronic obstructive pulmonary disease exacerbation (long term lung diseases that cause inflammation and damage to airways, making it difficult to breathe). Prednisone is a corticosteroid used to reduce inflammation and suppress an overactive immune system, treating a wide range of conditions…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2026-06-09 · tag F0756 — failed to review each resident's drug regimen — isolated
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, Pharmacist and Physician interviews, the facility failed to ensure the Pharmacist provided monthly medication regimen reviews that included a comprehensive review of the resident's medical record, including the medication administration record to identify medication irregularities. The Pharmacist medication regimen review (MRR) dated [DATE] through [DATE] did not identify irregularities related to ongoing Prednisone (a corticosteroid used to reduce inflammation and suppress an overactive immune system, treating a wide range of conditions including allergies, autoimmune disorders, and respiratory diseases) 20 milligrams (mg) order (3 tablets by mouth with breakfast for 5 days starting [DATE]. The medication regimen review dated [DATE] through [DATE] also did not identify irregularities related to the continued administration of Prednisone 20 mg, 3 tablets daily for 5 days starting [DATE]. Prednisone 20 mg, 3 tabs (60 mg) was administered from [DATE] through [DATE]. On [DATE],…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2026-06-09 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff, Physician, Pharmacy Quality Assurance Manager interviews, the facility failed to have effective systems in place to prevent a significant medication error. On [DATE] Resident #162 was seen in the emergency department (ED) for shortness of breath, dyspnea, chronic obstructive pulmonary disease (COPD) exacerbation and fluid overload and returned to the facility just before midnight. The ED Physician prescribed Prednisone 20 mg (milligrams) 3 tablets (total of 60 mg daily) at breakfast for 5 days. Prednisone is a corticosteroid used to reduce inflammation and suppress an overactive immune system, treating a wide range of conditions including respiratory diseases. Possible negative outcomes of receiving 60 mg of Prednisone longer than 5 days may include hyperglycemia (high blood sugar), psychotic disturbance (loss of contact with reality), fluid retention (excess fluid buildup in the body's tissues), decreased ability to fight infection, and a decrease in inflammatory mediators…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-06-09 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff, Nurse Practitioner (NP) and Physician interviews, the facility failed to obtain daily weights as ordered by the physician. This was for 3 of 8 residents reviewed for the provision of care in accordance with professional standards of practice (Resident #17, Resident #35, and Resident #129). Findings included: a. Resident #17 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure (CHF). A physician's order for Resident #17 dated last revised on 12/5/25 with a discontinue date of 4/14/26 revealed daily weights before breakfast. If (Resident #17) gained 3 pounds (lbs.) in 1 day or 5 lbs in one week, the physician was to be called. Resident #17's comprehensive care plan revealed in part a focus area for potential alteration in hydration related to diuretic (fluid pill) use. The goal was for Resident #17 to remain free from signs and symptoms of fluid overload such as edema (swelling), congestion, and sudden weight gain through the next review.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-09 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of nutritional approaches (Resident #79) and intravenous (into a vein) access (Resident #180). This was for 2 of 62 residents whose MDS assessments were reviewed. Findings included: 1. Resident #79 was admitted to the facility on [DATE]. A Hydration Evaluation (an assessment of dehydration risk) form for Resident #79 dated 3/24/26 revealed in part Resident #79 was at risk for dehydration related to medications received, the need for feeding assistance, and the presence of a pressure wound. The evaluation indicated she would benefit from additional hydration support. A physician's order for Resident #79 with a start date of 3/24/26 was for Resident #79 to receive Sodium Chloride 0.9 percent (%) solution use 60 milliliters per hour (ml/hr) intravenously for the diagnosis of rehydration for 1 day, total of 1000 ml. Discontinue dermoclysis (a medical technique for administering fluids…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-09 · tag F0805 — failed to prepare food in a form residents can eat — isolated
  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident, Speech Therapist, and staff interviews, the facility failed to serve food in a form that met the resident's needs for 1 of 1 resident (Resident #14) reviewed. Resident #14 had been ordered food that was pureed texture and was observed to receive a soaked dinner roll.The findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), dementia, Alzheimer's disease, and failure to thrive. A physician's order for a pureed texture and thin liquids consistency was ordered for Residet #14 on 4/22/26. A review of Resident #14's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident to have the ability to understand others and to make herself understood. The MDS indicated she was severely cognitively impaired and required setup or clean-up assistance when eating. Resident #14 had a swallowing disorder and was on a mechanically altered diet without any weight changes. A review of Resident…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-03-13 · tag F0641 — pattern
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. Resident #139 was admitted to the facility on [DATE]. The discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #139 was discharged to a short-term general hospital. A progress note written by the Social Worker on 1/22/25 at 2:44 PM stated Resident #139 was discharged from the facility at 12:45 PM and was transported home by his friend. During an interview with the MDS Coordinator on 3/12/25 at 1:15 PM, she stated the MDS should have been coded to home and her coding was an error. An interview with the Director of Nursing was held on 3/12/25 at 1:23 PM, at that time she stated the resident was discharged home. During an interview on 3/12/25 at 1:26 PM, the Administrator stated her expectation would have been the MDS information was coded accurately. 3. Resident #80 was admitted to the facility on [DATE]. A review of Resident #80's physician's orders revealed an order dated 1/3/25 for aspirin (an antiplatelet medication) 81 milligrams (mg) one tablet by mouth daily for transient ischemic…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-13 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident responsible party (RP) and staff interviews, the facility failed to include documentation in the medical record that the facility staff had spoken with the responsible party (RP) or resident regarding advance directives (Resident #110). This was for 1 of 5 residents reviewed for advance directive. The findings included: A review of the facility's policy titled Residents' rights Regarding Treatment and Advance Directives dated 3/1/22 and reviewed/revised on 3/1/24 revealed it is the policy of this facility to support and facilitate a residents' right to formulate an advance directive. On admission the facility will determine if the resident has executed an advance directive, and if not determine whether the resident would like to formulate an advance directive. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. Resident #110's medical record revealed Resident #110 was admitted to the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-13 · tag F0582 — isolated
  Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and Responsible Party (RP) interviews, the facility failed to provide a Centers for Medicare and Medicaid (CMS) Form 10123-Notice of Medicare Non-Coverage (NOMNC) within the required time frame. This was for 1 of 4 residents (Resident #129) reviewed for Beneficiary Notices. Findings included: Resident #129 was admitted to the facility on [DATE]. Review of Resident #129's NOMNC form revealed the effective date coverage of his current skilled nursing and therapy services service would end was 3/11/25. It further revealed Medicare would probably not pay for his skilled nursing and therapy services after that effective date, and Resident #129 might have to pay for any services he received. The form included Resident #129's rights to appeal the decision. It was dated as signed by Resident #129's RP on 3/12/25. On 3/12/25 at 9:43 AM an interview with the Social Worker (SW) indicated Resident #129 was being discharged from the facility that day. She stated she had multiple conversations…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-13 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews the facility failed to develop an individualized, person-centered comprehensive care plan to include the use of side rails (Resident #82 and Resident #119) and an anticoagulant (blood thinning) medication (Resident #129). This was for 3 of 27 residents whose comprehensive care plans were reviewed. Findings included: 1. Resident #82 was admitted to the facility on [DATE] with diagnoses including history of cerebral infarction (stroke). A review of Resident #82's record revealed an assessment titled side rail/entrapment risk evaluation dated 2/22/25 and completed by Nurse #1 revealed bilateral one quarter length side rails were to be used. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #82 was cognitively intact. The MDS indicated Resident #82 required partial to moderate assistance with bed mobility, transfers, and was non-ambulatory. The MDS revealed Resident #82 had impairment of one side of upper extremities and impairment of both…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-13 · tag F0700 — isolated
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review the facility failed to attempt to use alternatives prior to installing side rails for 2 of 3 residents (Resident #82 and Resident #119) reviewed for side rails. Findings included: 1. Resident #82 was admitted to the facility on [DATE] with diagnoses including seizure disorder and history of cerebral infarction (stroke). A review of Resident #82's record revealed an assessment titled side rail/entrapment risk evaluation dated 2/22/25 and completed by Nurse #1 revealed there was no question on the evaluation regarding attempts to use alternatives before using side rails. Nurse #1 was not able to be reached for interview. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #82 was cognitively intact. The MDS indicated Resident #82 required partial to moderate assistance with bed mobility, transfers, and was non-ambulatory. The MDS revealed Resident #82 had impairment of one side of upper extremities and impairment of both lower extremities.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-13 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to obtain a baseline thyroid function test for a resident who was taking Levothyroxine Sodium for 1 of 5 residents reviewed for unnecessary medications (Resident #123). Findings included: Resident #123 was admitted to the facility on [DATE]. Her active diagnoses included hypothyroidism. Review of Resident #123's physician order dated 11/1/24 revealed the resident was ordered Levothyroxine Sodium oral tablet 25 micrograms, give 1 tablet by mouth in the morning for hypothyroidism. Review of a consultant pharmacist recommendation to the physician dated 11/26/24 revealed the pharmacist recommended a baseline thyroid function test to be completed and repeated yearly while Resident #123 was taking Levothyroxine Sodium. The nurse practitioner wrote an order to obtain the lab as recommended. Review of a consultant pharmacist recommendation to nursing dated 12/18/24 revealed the pharmacist again recommended nursing obtain a baseline thyroid function test…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-01-25 · tag F0553 — failed to let residents help plan their care — isolated
  Allow resident to participate in the development and implementation of his or her person-centered plan of care.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the resident, Responsible Party (RP), and staff, the facility failed to facilitate the inclusion of a cognitively intact resident and her RP in the care planning process for 1 of 1 residents reviewed for the care planning process. The findings included: Resident #57 was admitted to the facility on [DATE]. The medical record indicated Resident #57's family member was her RP. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #57 was cognitively intact. A review of the care plan for Resident #57 on 1/22/24 at 1:00 PM revealed it was last revised on 2/28/23. A record review for Resident #57 revealed the last care plan meeting note was dated 6/6/23. This note indicated the Social Worker and the Rehabilitation Manager spoke with the Resident's RP and updated her on the Resident's progress. There were no other care planning meeting notes after this date. The record further revealed no evidence the resident or RP were incorporated in the care planning process…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$27,378 in federal fines across 2 penalties.

• $13,689 — penalty dated 2026-06-09
• $13,689 — penalty dated 2026-06-09

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to HARBORVIEW HEALTH SYSTEMS — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NC